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ObjectivesThe Pancreatitis Activity Scoring System (PASS) has been derived by an international group of experts via a modified Delphi process. Our aim was to perform an external validation study to assess for concordance of the PASS score with high face validity clinical outcomes and determine specific meaningful thresholds to assist in application of this scoring system in a large prospectively ascertained cohort.MethodsWe analyzed data from a prospective cohort study of consecutive patients admitted to the Los Angeles County Hospital between March 2015 and March 2017. Patients were identified using an emergency department paging system and electronic alert system. Comprehensive characterization included substance use history, pancreatitis etiology, biochemical profile, and detailed clinical course. We calculated the PASS score at admission, discharge, and at 12 h increments during the hospitalization.We performed several analyses to assess the relationship between the PASS score and outcomes at various points during hospitalization as well as following discharge. Using multivariable logistic regression analysis, we assessed the relationship between admission PASS score and risk of severe pancreatitis. PASS score performance was compared to established systems used to predict severe pancreatitis. Additional inpatient outcomes assessed included local complications, length of stay, development of systemic inflammatory response syndrome (SIRS), and intensive care unit (ICU) admission. We also assessed whether the PASS score at discharge was associated with early readmission (re-hospitalization for pancreatitis symptoms and complications within 30 days of discharge).ResultsA total of 439 patients were enrolled, their mean age was 42 (±15) years, and 53% were male. Admission PASS score >140 was associated with moderately severe and severe pancreatitis (OR 3.5 [95% CI 2.0, 6.3]), ICU admission (OR 4.9 [2.5, 9.4]), local complications (3.0 [1.6, 5.7]), and development of SIRS (OR 2.9 [1.8, 4.5]) as well as prolongation of hospitalization by a mean of 1.5 (1.3–1.7) days. For the prediction of moderately severe/severe pancreatitis, the PASS score (AUC = 0.71) was comparable to the more established Ranson’s (AUC = 0.63), Glasgow (AUC = 0.72), Panc3 (AUC = 0.57), and HAPS (AUC = 0.54) scoring systems. Discharge PASS score >60 was associated with early readmission (OR 5.0 [2.4, 10.7]).ConclusionsThe PASS score is associated with important clinical outcomes in acute pancreatitis. The ability of the score to forecast important clinical events at different points in the disease course suggests that it is a valid measure of activity in patients with acute pancreatitis.

Background T1 mapping is a robust and highly reproducible application to quantify myocardial relaxation of longitudinal magnetisation. Available T1 mapping methods are presently site and vendor specific, with variable accuracy and precision of T1 values between the systems and sequences. We assessed the transferability of a T1 mapping method and determined the reference values of healthy human myocardium in a multicenter setting. Methods Healthy subjects (n = 102; mean age 41 years (range 17–83), male, n = 53 (52%)), with no previous medical history, and normotensive low risk subjects (n=113) referred for clinical cardiovascular magnetic resonance (CMR) were examined. Further inclusion criteria for all were absence of regular medication and subsequently normal findings of routine CMR. All subjects underwent T1 mapping using a uniform imaging set-up (modified Look- Locker inversion recovery, MOLLI, using scheme 3(3)3(3)5)) on 1.5 Tesla (T) and 3 T Philips scanners. Native T1-maps were acquired in a single midventricular short axis slice and repeated 20 minutes following gadobutrol. Reference values were obtained for native T1 and gadolinium-based partition coefficients, λ and extracellular volume fraction (ECV) in a core lab using standardized postprocessing. Results In healthy controls, mean native T1 values were 950 ± 21 msec at 1.5 T and 1052 ± 23 at 3 T. λ and ECV values were 0.44 ± 0.06 and 0.25 ± 0.04 at 1.5 T, and 0.44 ± 0.07 and 0.26 ± 0.04 at 3 T, respectively. There were no significant differences between healthy controls and low risk subjects in routine CMR parameters and T1 values. The entire cohort showed no correlation between age, gender and native T1. Cross-center comparisons of mean values showed no significant difference for any of the T1 indices at any field strength. There were considerable regional differences in segmental T1 values. λ and ECV were found to be dose dependent. There was excellent inter- and intraobserver reproducibility for measurement of native septal T1. Conclusion We show transferability for a unifying T1 mapping methodology in a multicenter setting. We provide reference ranges for T1 values in healthy human myocardium, which can be applied across participating sites.

Workplace bullying is a serious problem in organizations. This study examined the effects of workplace bullying on compulsory citizenship behavior in the work domain and spousal well-being in the family domain. Workplace bullying was viewed as a reality in organizations, and individuals’ judgments concerning various features of their workplace situations were considered. We hypothesized that employees’ experiences of workplace bullying influence their compulsory citizenship behavior and cross over to influence their spouses’ well-being through anger. A total of 796 employee-spouse dyads from a large manufacturing industry and a public sector institution in Taiwan were selected as participants. A time-lag study design and two different sources (employees and their spouses) were utilized to reduce common method bias. The results demonstrate that workplace bullying is significantly related to compulsory citizenship behavior, anger, and spousal well-being. In addition, anger is an important mediator between workplace bullying and its consequences, both at work and at home. These findings have implications for better understanding employee conditions and their associations with social issues in the workplace.

BackgroundNumerous models have been developed to predict choledocholithiasis. Recent work has shown that these algorithms perform suboptimally. Identification of clinical predictors with high positive and negative predictive value would minimize adverse events associated with unnecessary diagnostic endoscopic retrograde cholangiopancreatography (ERCP) while limiting the use of expensive tests including magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) for indeterminate cases.MethodsConsecutive unique inpatients who received their first ERCP at Los Angeles County Medical Center between January 2010 and November 2016 for suspected bile duct stones were reviewed. The primary outcome was the proportion of patients with specific combinations of liver enzyme patterns, transabdominal ultrasound, and clinical features who had stones confirmed on ERCP. As a secondary outcome, we assessed the performance of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification algorithm in our population.ResultsOf the 604 included patients, bile duct stones were confirmed in 410 (67.9%). Detailed assessment of liver enzyme patterns alone and in combination with clinical features and imaging findings yielded no highly predictive algorithms. Additionally, the ASGE high-risk criterion had a positive predictive value of only 68% for stones. For the 236 patients for whom MRCP was performed, this imaging modality was shown to have highest predictive value for the presence of stones on ERCP.ConclusionExhaustive exploration of various threshold values and dynamic patterns of liver enzymes combined with clinical features and basic imaging findings did not reveal an algorithm to accurately predict the presence of stones on ERCP. The ASGE risk stratification criteria were also insensitive in our population. Though desirable, there may be no “perfect” combination of clinical features that correlate with persistent bile duct stones. MRCP or EUS may be considered to avoid unnecessary ERCP and associated complications.

Background Aggressive dose reduction strategies for cardiac CT require the prospective selection of limited cardiac phases. At lower heart rates, the period of mid-diastole is typically selected for image acquisition. We aimed to identify the effect of heart rate on the optimal CT acquisition phase within the period of mid-diastole. Methods We utilized high temporal resolution tissue Doppler to precisely measure coronary motion within diastole. Tissue-Doppler waveforms of the myocardium corresponding to the location of the circumflex artery (100 patients) and mid-right coronary arteries (50 patients) and the duration and timing of coronary motion were measured. Using regression analysis an equation was derived for the timing of the period of minimal coronary motion within the RR interval. In a validation set of 50 clinical cardiac CT examinations, we assessed coronary motion artifact and the effect of using a mid-diastolic imaging target that was adjusted according to heart rate vs a fixed 75% phase target. Results Tissue Doppler analysis shows the period of minimal cardiac motion suitable for CT imaging decreases almost linearly as the RR interval decreases, becoming extinguished at an average heart rate of 91 bpm for the circumflex (LCX) and 78 bpm for the right coronary artery (RCA). The optimal imaging phase has a strong linear relationship with RR duration (R 2  = 0.92 LCX, 0.89 RCA). The optimal phase predicted by regression analysis of the tissue-Doppler waveforms increases from 74% at a heart rate of 55 bpm to 77% at 75 bpm. In the clinical CT validation set, the optimal CT acquisition phase similarly occurred later with increasing heart rate. When the selected cardiac phase was adjusted according to heart rate the result was closer to the optimal phase than using a fixed 75% phase. While this effect was statistically significant (p < 0.01 RCA/LCx), the mean effect of heart-rate adjustment was minor relative to typical beat-to-beat variability and available precision of clinical phase selection. Conclusion High temporal resolution imaging of coronary motion can be used to predict the optimal acquisition phase in cardiac CT. The optimal phase for cardiac CT imaging within mid-diastole increases with increasing heart rate although the magnitude of change is small.

Introduction: The most frequent complication following endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). There are limited studies investigating the risk of PEP in patients undergoing ERCP for the indication of gallstone pancreatitis. Methods: We evaluated consecutive ERCPs from 2010 to 2016. PEP was defined as the onset of epigastric pain with an intensity of 3/10 on the visual analog scale (VAS), amylase or lipase greater than 3 times upper limits of normal, and/or corresponding radiological images. Our management algorithm for gallstone pancreatitis is to perform ERCP once pain has resolved and lipase or amylase have decreased by at least 30%. PEP in these patients was defined as an increase in sustained (24 hours) epigastric pain following ERCP by 3 point on the VAS accompanied by an increase in amylase or lipase from the value immediately prior to ERCP. The primary outcome was rate of PEP amongst patients undergoing ERCP for gallstone pancreatitis versus those with all other indications. Secondary outcomes include length of hospitalization, mortality, and severity of PEP. Results: 8 out of 235 (3.42%) patients who underwent ERCP for gallstone pancreatitis developed PEP compared to 62 out of 1343 (4.62%) patients with other indications (OR 0.74 [95% CI 0.34-1.61]) (Table1). The median number of days between admission and ERCP was greater in those who developed PEP, 3 (IQR 2-5), versus those who did not 2 (IQR 0-4). In multivariate analysis, male gender had lower rate of PEP as seen in previous studies (OR 0.46 [95% CI 0.25-0.85]). Multivariate logistic regression including clinically significant variables such as time to ERCP, gender and demographics confirmed no significant relationship between the indication for gallstone pancreatitis and PEP (OR 0.53 [95% CI 0.251.13]). Interestingly, those with gallstone pancreatitis who developed PEP had average hospitalization of 12.1± 6.1days versus 8.5±4.9days in those without gallstone pancreatitis. However, close examination revealed that this was primarily related to delayed inpatient cholecystectomy. Conclusion: Our large cohort investigation into risk factors of PEP did not show an association between PEP and gallstone pancreatitis, an indication for ERCP. Our approach to allow patients with gallstone pancreatitis to \"cool off\" may have played a role in our finding. Our management algorithm in timing ERCP with resolution of gallstone pancreatitis requires prospective, controlled study.